1. دكتوراه بورد عربي جراحه الكلى
بسم الله الرحمن الرحيم Urology Congenital anomalies of the upper urinary tract
د.أشرف إبراهيم العدول
دكتوراه بورد عربي جراحه الكلى
مدرس ـ فرع الجراحة
M.B.Ch.B., CABMS(Uro).

2. Ureteropelvic Junction (UPJ)(PUJ) Obstruction (stenosis)
The most common cause of significant dilation of the collecting system in the fetal kidney
Boys > Girls
Left-sided lesions predominate
15% bilateral
ETIOLOGY
Intraluminal : mucosal fold that causes valve like effect.
Intrinsic (intramural) interruption in the development of the circular musculature of the UPJ
Extrinsic An aberrant, accessory, or early-branching lower-pole renal artery

3. PUJ Obstruction – gross pathology

4. SYMPTOMS/PRESENTATION
Most infants are asymptomatic
Most children are discovered because of their symptoms
Episodic flank or upper abdominal pain, sometimes associated with nausea and vomiting
DIAGNOSIS
U/S: hydronephrosis
IVU: diagnostic , hydronephrosis with fixed stenotic segment or complete obstruction
CT scan: hydronephrosis that ends abruptly
Magnetic Resonance Imaging
Radionuclide Renography: to see the split function of each kidney
Pressure-Flow Studies : Whitaker test

5. Treatment: Medical: control infection and pain. Surgical:
Indications for surgery:
1-progressive hydronephrosis.
2- UTI, and symptomatic patients.
3- Severe hydronephrotic non functioning kidney.
4- Stone formation

6. Endoscopic Approaches balloon dilatation Antegrade endopyelotomy
Treatment
SURGICAL REPAIR including open surgical techniques, laparoscopic, & endoscopic approaches
Open & laparoscopic surgical techniques Anderson-Hynes dismembered pyeloplasty: excision of the pathologic UPJ & appropriate reanastamosis or flap technique or flap operation
Endoscopic Approaches
balloon dilatation
Antegrade endopyelotomy
Nephrectomy for non functioning kidney

9. Bilateral PUJO

10. Ectopic Ureters 80% are associated with a duplicated collecting system
In the male, the posterior urethra is the most common site of termination, also to semenal vesicle
In the female, the urethra and vestibule are the most common sites
Clinical features: According to the site of orifice
In females: continuous dribbling
In males: urinary tract infection
Diagnosis IVU, U/S, CT scan, cystoscopy
Treatment: Ureteric reimplantation to urinary bladder or implantation of one ureter to the other ureter is used
Ectopic ureters may drain renal moieties (either an upper pole or a single-system kidney) that have minimal function. Therefore, upper pole partial nephrectomy (or nephrectomy of single system) is sometimes recommended

11. Ureteroceles
Is due to congenital atresia of the ureteric orifice which causes a cystic dilatation of the intramural portion of the ureter
Women > men
Sometimes involves with ectopic ureter
More prone to stone disease & UTIs
Clinical Features : asymptomatic
Repeated UTIs, Hematuria
Diagnosis
IVU, cystoscopy, cystogram
The ‘adder head’ on excretory urography
is typical.
Treatment
Asymptomatic : no treatment
Cystoscopy with diathermy cauterization of the hole
Nephrectomy in non functioning kidney
In complicated cases, ureteral reimplantation and vesical reconstruction

12. Cobra (Adder) head appearance of ureterocele

13. Ureterocele involving single system Ureterocele involving duplicated ureter

14. Congenital Megaureter
Grossly dilated ureter
Unilateral or bilateral
More common in male
Clinical features:
Asymptomatic, pain, repeated UTIs
lower ureter might be obstructed
sometimes associated with vesicoureteral reflux
Diagnosis : IVU

15. Treatment Infection should be controlled
Excision of the lower stenotic segment (if present)
Ureteric tapering & reimplantation in
to the bladder
Nephroureterectomy for non functioning kidney

16. Postcaval (Retrocaval) ureter (Preureteral Vena Cava )
The right ureter pass behind the inferior vena cava
This might causes obstruction
It is a vascular abnormality
Incidence: about 1 in 1500
Although it is congenital, most patients present at 3rd or 4th decade.
Diagnosis: IVU
Treatment
surgical correction involves ureteral division, with relocation and ureteroureteral or ureteropelvic reanastomosis, usually with excision or bypass of the retrocaval segment, which can be aperistaltic

18. Renal surgical infections

19. Renal surgical infections
Urinary tract infection (UTI) is an inflammatory response of the urothelium to usually bacterial invasion that is usually associated with bacteriuria and pyuria.
Classification
Non specific
Specific ( T.B. & Bilharziasis )
Acute
Chronic

20. Non specific acute infection
Bacteriology:
E.coli ( most common)
Proteous, Staph aurious, Klebsiella
Pathogenesis:
Ascending infection: most common route
Hematogenic
Lymphatic
Direct extension

21. Susceptibility Bacterial virulence Extrinsic factors : male & female
Introitus
Urethra
Prepuce
Intrinsic factors: Bladder, ureteral & renal

22. Bacterial persistence
Urinary calculi
Obstructive uropathy
Renal pathology
Urethral infection
Foreign bodies
Urogenital & intestinal fistulae

23. Kidney Infections Acute pyelonephritis Clinical features:
Defined as inflammation of the kidney and renal pelvis
It is a clinical syndrome of chills, fever, and flank pain that is accompanied by bacteruria and pyuria, a combination that is reasonably specific for an acute bacterial infection of the kidney.
Female > male
Clinical features:
Constitutional symptoms
Flank & hypochondrial pain
Frequency, urgency, & dysuria

24. Investigations
GUE
Urine +/- blood culture & sensitivity
U/S
KUB
IVU

25. Treatment Depends on the severity of the infection
Admission to the hospital, Bed rest
Parenteral broad spectrum antibiotics until results of C&S
Analgesics
Encouraged copious fluid
intake otherwise give IVF
N.B. obstructive
Pyelonephritis needs
drainage

26. Pyonephrosis
Pyonephrosis refers to infected hydronephrosis where the kidney is converted into a sac containing pus associated with suppurative destruction of the parenchyma of the kidney, in which there is total or nearly total loss of renal function.
It is usually unilateral
Causes
Infected hydronephrosis
Following acute pyelonephritis
Complication of renal calculus disease

27. Investigations CLINICAL FEATURES The patient is usually very ill
Flank pain & Tenderness
High fever ,chills
Anaemia
Investigations
GUE + C&S + blood C&S
CBC
KUB
U/S
IVU
CT scan

28. Treatment It is Surgical Emergency that needs drainage
Parenteral antibiotics
Drainage of the kidney
..nephrostomy: --percutaneous
-- open
.. JJ stint
The stone is removed
nephrectomy

31. Renal Abscess or Renal Carbuncle
Renal abscess or carbuncle is a collection of purulent material confined to the renal parenchyma.
The renal parenchyma contains an encapsulated necrotic mass
Insidious onset (may run > 2 weeks)
Obscure fever
Local pain
Symptoms of the primary cause
Tender renal angle
Tender mass : differentiate from malignant lesion

32. Bacteriology Hematogenic infection
Commonly coliforms & staph aureous, proteous, klebsiella.
Predisposing factors
Diabetic patients
I.V drug therapy
Hemodialysis
Immunocompromized
Skin infection
Rarely ascending infection

33. Clinical picture Usually underlying pathology:
systemic bacterial infection, skin infections, urinary stones, vesicoureteric reflux, obstruction, DM
Infection—liquefaction—abscess formation
Male : female :1
Age : year
Loin Pain
Fever
On exam.: renal angle tenderness

34. Investigations GUE ???? Urine C&S ???? Blood culture ???? U/S KUB, IVU
WBC:Leuckocytosis
U/S
KUB, IVU
CT scan

35. Surgical: Abscess drainage
Treatment
Medical: Rest
Analgesia
Antibiotics
Follow up examination
Surgical: Abscess drainage
Nephrectomy

36. Perinephric Abscess Route of infection: Rupture of renal abscess
Infected perinephric hematoma or urinoma
Extension from nearby organs: Appendix, Gall Bladder, Pelvic organs.
Hematogenic: Tonsillitis, boils etc.

37. Bacteriology
Ecoli
Staph aureous
Proteous
Klebseilla

38. Pathology
Cortical abscess coallese, enlarge, rupture to the perinephric space, form a perinephric abscess
Fluid filled inflammatory mass
Thick wall, adhesions.

39. Clinical picture
Fever , rigor
Dysuria, frequency
Renal tenderness
Visible loin mass, tender, +ve fluctuation

40. Investigations Leucocytosis, Anemia Pyurea, +ve bacterial culture U/S
CT scan
KUB : soft tissue mass, stones.
IVU , Tomography
Chest x ray : ? Reactionary pleural effusion

41. Treatment Bed rest Antibiotics & analgesics
Always combined with drainage:
Under U/S or CT- scan guidance
Open drainage

44. Chronic non specific infection Xanthogranulomatous Pyelonephritis
Rare, severe, chronic renal infection typically resulting in diffuse renal destruction.
Commonly affect middle age
Mixed bacteria: E. coli, Proteous mirabilis
Predisposing factors:
Diabetic
Renal stone disease
Neurogenic uropathy
Obstructive uropathy

45. Macroscopic appearance: Excessive fatty infiltration, Xanthene deposit
Clinical picture
Chronic
Loin pain
Low grade fever & malaise
Weight loss
Renal mass
Multiple fistulae
Macroscopic appearance: Excessive fatty infiltration, Xanthene deposit

46. Investigations
GUE
KFT
U/S
CT scan
KUB
IVU

47. Treatment
Always surgery… Nephrectomy
Under antibiotic cover

48. prostatitis Acute prostatitis
Bacteria: E. coli, staph aureus, S. faecalis, N. gonorrhoea
Route of infection: -Hematogenous
-2ry to UTI

49. Clinical features Fever, shivering , rigor Backache, perineal pain
Irritative voiding symptoms: dysuria, frequency
Obstructive urinary symptoms
Pain on defecation
O/E: DRE : enlarged, extremely tender, hot, soft prostate

50. Treatment
Admission ?
Bed rest
Analgesics
Antipyretics
Parenteral antibiotics
If abscess: drainage
If retention: suprapubic catheterization.

51. Specific infections of the urinary tract Renal Tuberculosis
Bacteria: Mycobacterium TB
Pathogenesis: Hematogenic
Start unilateral , late bilateral affection.
The 1st lesion starts usually in the pyramids
Chronic: Asymptomatic until late stage
TB granuloma, caseation, open to the calyces.
Renal destruction, calcification.
The ureteric upper & lower 1/3rd is affected
Ureteral & bladder involvement is commonly secondary to renal T.B.

52. Clinical picture
Always suspect if:
Endemic area
Age : year
Male : female :1
Chronic symptoms
Non responsive UTI to adequate therapy.
Unexplained hematuria.
loin pain

53. Night sweating, Wt loss
Fever when secondary bacterial infection
Chronic renal sinuses.
TB is the most common opportunistic infection in AIDS patients

54. Investigations GUE : RBC , Sterile acid pyuria. -ve urine C&S
Three successive morning urine samples for AFB.
24 hours urine collection for AFB.
TB culture & sensitivity.
ESR
WBC total & differential.
KUB: Renal calcification
IVU
CXR
Cystoscopy: for lower tract involvement.

55. Treatment
Medical:
Surgical:
If complicated
No clinical control
Correct obstruction
Nephrectomy.

56. Complications
Perinephric abscess
Pyonephrosis
Renal stones
Ureteral strictures
Renal cutaneous sinuses
Chronic renal failure.
Autonephrectomy in ureteral obstruction
Bladder contracture (thimble bladder)

57. Bilharziasis Trematode: schistosoma haematobium Male: female 3:1
Endemic in Nile valley, Iraq, & middle east in general.
Marshes & slow running fresh water is the habitat of the fresh water snail ( bulinus truncatus ) which is the intermediate host.

58. Mode of infestation
The bifid tailed embryos (cercariae) penetrate the skin, enter the blood vessels, flourish in the liver, develop into male & female worms, they pass to the vesical venous plexus
The female pass to the submucous venule to lay its eggs with its terminal spine which penetrate the vessel wall & pass with urine & if reach fresh water it penetrates the intermediate host.

59. Clinical features
Urticaria ( swimming itch )
Fever , sweating
Hematuria: intermittent, terminal
Lymphadenopathy & splenomegaly

60. Investigations
GUE : early morning samples for several consecutive days – ovae with terminal spines
Leukocytosis – eosinophilia
Cystoscopy
Bilharzial pseudotubercles , nodules, sandy patches, ulceration, fibrosis, granulomas, papillomas, carcinoma (SCC).

61. Imaging study
KUB
U/S

62. IVU

63. Treatment
Antimony e.g. praziquantel & metriphonate
Papilloma : endoscopic removal
Carcinoma : radical cystectomy

64. Complications
2ry bacterial infection
Vesical & ureteric calculus formation
Terminal ureteric stricture : needs dilatation or ureteric reimplantation
Prostatoseminal vesiculitis
Fibrosis of the bladder & bladder neck
Urethral stricture & fistula formation.
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